Intestinal Volvulus

Small intestinal volvulus is a very rare entity in the western world. The corollary is true. It is very common in many other countries. In fact, it is reported to be the commonest cause of intestinal obstruction in parts of the world like Ethiopia. It is also called mid gut volvulus.

This occurs when the intestine twist around it self, causing a close loop blockage of the lumen of the small or mid gut.

Small intestinal or mid gut volvulus is often associated with a malrotation of the mid gut. It is however a very different entity from mal rotation.

Intestinal volvulus is a dire surgical emergency. If the twisting involves the large artery supplying the mid gut (superior mesenteric artery), that portion could rapidly become gangrenous (death of the tissue). Loss of mid gut is not compatible with life.

Causes of Intestinal Volvulus

Cases of intestinal volvulus in man have been more commonly reported in Iran, India, Afghanistan, and Zimbabwe. It is postulated to be due to the consumption of very large amount of high residue diet.

Spider-web-like materials called adhesions following surgical operations in the abdomen could lead to these entangling the small intestines, and provide a fulcrum for twisting.

Stomach by-pass surgery for obesity (bariatic surgery) involving the Roux-en-Y surgical anastomosis could be complicated by small intestinal volvulus.

Rarely, ventriculo-peritoneal shunts for hydrocephalus could be complicated by the development of intestinal volvulus.

The pain could start off suddenly or gradually and worsen over a period of time. There would be associated vomiting and distension of the tummy.

The patient may be very shocked, more than can be explained by the physical findings. Patient may pass blood in stool. Fever sets in quickly from colonisation of the dying small bowel by gut occupying bacteria.

If treatment and urgent surgery is not undertaken, death is imminent.

Tests Available

Doctors may wish to do a combination of the following investigations to confirm the presence of a sigmoid volvulus:

BLOOD TEST

Like most times, your doctor may want to run a CBC (complete blood count) also called FBC (full blood count in non-American English World). This is a crude test that will show if you have infection or anaemia. If the blood count is low, it may indicate or suggest the presence of tumour in the cause of the bowel obstruction from the volvulus. Please note that it is a crude test again! The CBC on its own does not confirm the presence of tumour. A low blood count may mean that you may get blood transfusion. Even though the operation to relieve volvulus is a major operation, it is not compulsory that you get blood transfusion.

Another blood test that your doctor would want to do in the emergency department is what is called Electrolyte and Urea (E/U) test. It will shed light on how your kidneys and liver are working. It may help to decide if you are fit for surgery immediately, or if you will need further treatment before theatre.

X-RAY

A normal plain abdominal x-ray will demonstrate a huge air filled distended small bowel.

Emergency CT Scan

Many surgeons would increasingly want to confirm the diagnosis of small bowel obstruction in intestinal volvulus by arranging and having an urgent CT (computed tomography)scan done. This is a special form of X-ray where the patient lies on on trolley and is passed through a huge donut-like machine. It is extremely helpful in confirming diagnosis of bowel obstruction.

Treatment

Doctors from the department of paediatric surgery at the University Medical Centre Nijmegan in the Natherlands reported a case of a 9 year old boy in 2003, who lost the whole length of this small intestinal due to small intestinal volvulus. There was a need to have small intestine transplantation or feeding the child for the rest of his life through the veins.

This highlights the point that small intestinal volvulus is a very serious problem.

In those with chronic small bowel volvulus, the small bowel (intestine) could keep twisting and untwisting.
When there is difficulty in untwisting, chronic small intestinal volvulus can present as an acute problem.
The treatment here is nothing but surgery.

The cause of the volvulus is sort and dealt with. Mesenteric lipomas, swallowed foreign objects like magnet, are remediable causes.

Any gangrenous part of the small intestine is removed.

If length of small intestine removed is two much, patient may need to be feed for life through the vein.

There is also the option of small intestine transplantation.
Small intestine transplantation is not as successful as kidney or liver transplantation.

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